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Best Practice for a Community High Utilization Program – Common Community IT Platform

Critical to the success of any community-wide high utilization program is the ability to share pertinent information amongst community members.  This is particularly challenging within the healthcare industry, where health systems utilize a wide number of information platforms and information is rarely shared across platforms.  And added to this we must consider the sensitive nature of the psychosocial issues experienced by high utilization patients, often encompassing issues such as behavioral health and substance use, which carry their own set of regulatory compliance guidelines around information sharing.  Most community care systems – hospitals, jails, law enforcement agencies, out-patient medical providers, mental health institutions, substance treatment programs, court systems, and housing authorities (to name just a few) – have transitioned to electronic record-keeping, but in most cases information sharing is very limited within systems of care (say, between hospital, or between law enforcement agencies), and extremely rare across systems.

Being able to share pertinent information amongst all members of a care community is critical; if we can’t share information, we might all be working towards a common goal, but we are essentially speaking different languages, with a very limited understanding of what each other is doing.  This invariably leads to poor organization, duplication (often multiplication) of efforts, and ultimately wasted community time and resources.  Multiple agencies may be doing great work, but often in a vacuum, with the patient lost amongst an array of poorly coordinated efforts.

To help facilitate greater success, CBC Solutions recommends Collective Medical to make this critical information sharing possible. The Collective Platform seamlessly connects each member of a patient’s care team together for effective collaboration on even the most complex patients. Their platform empowers physicians, nurses, and other care providers to improve the quality and efficiency of patient care through actionable real-time patient notifications. Their nationwide network of engaged care team members offers transparency for providers through patient histories and collaborative care plans—identifying vulnerable patients in real-time and helping care teams address their needs at the point-of-care.

Fortunately, within the last decade, significant progress has occurred in implementing systems of “common language” across communities.  Many health systems now have electronic record systems that can be shared amongst all members of that system, and regional government programs have provided much-improved data sharing in certain target communities. But arguably the greatest progress has occurred via the adoption of platforms that allow for HIPPA secure data sharing across institutions, care systems, and in some cases across the county and state lines.   It is very common for an emergency physician to have access to care plans, recent visit histories, and information on prescriptions that may have been filled even earlier that day when certain platforms are in use within or across states.  In the state of Washington (where I reside and practice) we experienced a 15% decrease in frequent utilizer emergency department visits just by the implementation of a state-mandated common data-sharing platform in 2011.

We feel the criteria for a valuable community-wide IT platform include:

  • Ability to interact with all community electronic medical records
  • Ability to engage with state Prescription Monitoring Programs databases
  • Serve as a portal for prompt sharing of customized patient care plans
  • Allows for data sharing across state lines
  • Can be shared with multiple community partners in HIPPA compliant fashion
  • Immediate access by appropriate end-user providers – Emergency department personnel, admission hospital personnel (hospitalists, social workers and hospital-based care coordinators), and out-patient providers (primary care providers and patient care specialists)

A high functioning common community IT platform is a critical component in the success of any community-based high utilization program. CBC Solutions is proud to partner with Collective Medical to facilitate a successful outcome for communities.

You can review other Community High Utilization Program Best Practices, and find additional information HERE.

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Best Practice for a Community High Utilization Program: Community Resource Engagement

High utilization patients are typically identified as having high emergency department visits, frequent hospital admissions, or high medical cost utilization. But in almost every case these patients are high utilizers of a vast number of community resources. True patient and community improvement occur only when we can identify these resources and engage them all in dialogue towards client improvement. Historically, failure to achieve this within a community has resulted in duplication (often multiplication) of care efforts, ineffective cost allocations, and most egregiously less-than-ideal identification and addressing of client needs.

Actually, while identifying the various resources involved in an individual’s care is a good first step in community resource engagement, true effective resource management requires much more –  we have to recognize how the client is affecting each resource, where opportunities for improvement may exist, understand and promote common efforts towards client (and resource) needs, and communicate our common efforts effectively across the community of care.

Some community resources that must be engaged in early dialogue are fairly intuitive:

  • Hospitals (particularly emergency department personnel, hospitalists, and social workers)
  • Community Care Coordination services
  • Primary Care Offices (and Specialty Care Offices)
  • Psychiatric Care Facilities and Behavioral Health Centers
  • Substance Use Rehabilitation Centers

Other resources may not be engaged as frequently, but are just as vital for success:

  • Local housing and transportation authorities
  • EMS and Law Enforcement Agencies
  • Food and clothing services
  • Jails and Therapeutic Court Agencies
  • Protective Service Agencies

High utilization program staff are in a unique position to coordinate efforts across the community of care, but to do so effectively they must spend time with each community resource, understanding how and where client engagement issues occur.  Staff must become familiar with each resource’s communication techniques, and help facilitate client communication amongst community resources in a compliant fashion.

One very effective tool that can promote community resource inter-communication is the creation of a monthly high-utilization client forum. This provides an opportunity for various community resources to meet together on a frequent basis to discuss common client issues together. Program staff can host these meetings, making sure to invite each of the resources invested in a client’s care in attendance. Given the sensitive nature of the discussions, and in accordance with CFR-42 (Code of Federal Regulations #42), clients must give consent for their information to be shared in such a forum.  We recommend a written consent form identifying all individuals that will be involved in said discussions, and signed by the client before any such dialogues occur. You will find that these multi-disciplinary forums will quickly become a staple in community program development.

To learn more, contact us today!

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Best Practice for a Community High Utilization Program – Staff live in communities being served

A small but significant portion of individuals in communities around the country struggle with psychosocial issues – homelessness, mental health challenges, substance use and addiction, and/or challenging medical conditions. Their needs often go unmet, leading to high resource utilization or crisis events. They are typically identified by meeting one or more of the following criteria:

  • Frequency of ED visits or hospitalizations in a given period of time
  • Top % of cost of members within a community (often the top 1-2% or a payer cohort)
  • Identified by a community resource as a high utilizer of their services

Frequently these individuals already have some form of assigned care coordination. But the needs of these

individuals are unique; standard telephonic or off-site care coordination practices are not substantial enough. This small cohort of individuals is best served by staff available within the community, familiar with their unique needs, and with intimate knowledge of community resources. We recommend each community have a dedicated regional program coordinator, – a licensed RN or MSW with care coordination experience – working with a team of community workers, as well as targeted administrative support.

Staff in these programs spend the majority of the time – in many cases over 90% of their time – in the field! The initial period of program enrollment tends to be the most time consuming; some studies have shown that up to 20% of staff’s time with clients occurs during the first month of program enrollment. Within days of enrollment team members should meet with new clients to conduct an intake assessment. The initial intake should be done in a calm environment, if possible in the client’s residence; it is an opportunity for to identify perceived risks, goals, history (medical, behavioral and social), perceived hurdles, and pertinent demographic information. This is also an opportunity for staff to begin dialogue with clients on initial service opportunities available to address their needs.

Early “wins” are crucial, and we highly encourage staff to address issues as they are identified wherever possible.
Within the first month of program enrollment, staff should create an individualized care plan for each client (care plan creation is the focus of an upcoming article), and promote its availability within the community. Following, or in some cases simultaneously with, care plan creation, staff work with clients to prioritize and begin to address identified needs – this often involves assisting with accesses to rehab or treatment programs or perhaps aiding with obtaining housing or transportation. Early in program enrollment staff often escort individuals to their office visits.

Throughout enrollment, staff will typically engage clients (and update their care plans accordingly):

• During or immediately after each emergency department visit
• During every medical or mental health admission
• After most primary care and/or specialist office visits
• Upon client requests for any variety of requests

This level of intense client resource management does make a significant difference – within months of enrollment community resource are used more effectively, and crisis events decrease. Staff live within communities being served is THE main differentiator of a successful high utilization program.

Read More | Posted In: model of care, News

Improving care for high resource patients

An opportunity too costly to miss out on

We have an opportunity within healthcare to make an impact – a huge impact…

Healthcare costs now consume 18% of the GDP, $3.5 trillion in 2017 (1).  But a very small cohort of individuals account for an inordinate amount of this expenditure – the Department of Health and Human Services informs us that 1% of individuals account for 21% of all healthcare costs (2).  While a portion of these patients have few options other than expensive medical treatments, a significant portion of this cohort struggle with psychosocial issues that are poorly addressed in many communities, resulting in significant unnecessary expenses.  According to 2016 CDC data, almost a fifth of annual emergency department visits, a total of over 24 million visits at a cost of $11.2 billion, are attributed to frequent utilizers – those with 5 or more visits within the prior 12 months.  Amongst frequent ED utilizers nationwide:

  • 30% are homeless
  • 40% have a primary mental health disorder
  • 50% have a primary substance abuse disorder

When these individuals struggle in accessing the service they need and crisis ensues, they come to the one place they know will always be open – their local ED. We are blessed with wonderful emergency medical services throughout our nation, but our ED’s are not designed nor equipped to address these issues.  At best EDs can address the medical crisis that may be immediately at hand, but typically the patient is discharged back into the same environment, and when the next crisis invariably occurs, the cycle repeats itself.

Over the last decade, frequent utilizer programs in New Jersey (3), North Carolina (4), Minnesota (5), Maryland (6), Washington (7), Oregon (8) and Alaska (9) have all demonstrated dramatic success – reductions in hospital utilization varying from 40-60% within a year of program implementation, with dramatic net cost savings, demonstrated in each of these programs, and a cadre of metrics indicating improved quality of care.  Most of these programs are designed around models of care that can be reproducible within almost any community across the country. While each of these programs have components that are customized to communities, there are traits that are shared across all of the programs and other traits that are common amongst many of them, and repeatedly found to bring significant value when implemented.

This is the first of a short series of articles.  We hope in this introductory article we have heightened your awareness of this very important issue our nation is facing.  Over the next few weeks we will be sharing  a series of articles, each of which will highlight each of the following “best practices” shared by successful high utilization programs implemented across our country to date:

  • Staff live in communities being served
  • Community resource engagement
  • Customized patient care plans
  • Common community IT system
  • Immediate access fund
  • At-risk payment models

High utilization patients have suffered for decades as our medical communities have struggled to address their needs.  We now know that we can do better.   We can make a difference – a significant difference.  It is time to make an impact….



  1. National Health Expenditure Data, 2018 – CMS.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata
  2. Department of Health and Human Services Statistical Brief #421: Differentials in the Concentration in the Level of Health expenditures across Populations Subgroups in the U.S., 2010. file:///Users/papa/Dropbox/CBCS/Articles/Costs%20of%20Utilizer%20Care/AHRQ%20-%20Cost%20of%20Top%201%25,%202010%20-%20STATISTICAL%20BRIEF%20%23421_%20Differentials%20in%20the%20Concentration%20in%20the%20Level%20of%20Health%20Expenditures%20across%20Population%20Subgroups%20in%20the%20U.S.,%202010.htm
  3. Camden Coalition Hot Spotting Program – https://hotspotting.camdenhealth.org/
  4. Community Care of North Carolina – https://www.communitycarenc.org/
  5. Hennepin Health – https://www.commonwealthfund.org/publications/case-study/2016/oct/hennepin-health-care-delivery-paradigm-new-medicaid-beneficiaries
  6. Health Care Access Maryland –  http://www.healthcareaccessmaryland.org/media-listing/access-health-program-achieves-demonstrable-reductions-in-avoidable-hospital-utilization-by-addressing-social-determinants-of-health-and-linking-residents-with-community-resources/
  7. Consistent Care Program – https://consistentcare.org/
  8. The Health Commons Project – https://oregon.providence.org/our-services/c/center-for-outcomes-research-and-education-core/population-health-dashboards/the-health-commons-project/
  9. Mat-Su Health Foundation HUMS Program – http://www.healthymatsu.org/What-We-Do/Strategies/minds-1.html

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CBC Solutions’ Model of Care

CBCS’s base model of care involves an annual enrollment fee per member, with dramatically reduced annual renewal fees.  These fees are based on a guaranteed costs reduction of 30% within the first year of program implementation.  This service model is not intended to replace existing models of service within the community and/or organization; indeed, our organizational history shows existing resources invariably welcome the synergism our services provide and become our greatest proponents within short order of program implementation.

CBCS recognizes that certain communities and/or organizations prefer to retain services such as ours within their current systems of care, and for such organizations, we have developed partnership and consultation models of care.

CBCS welcomes an opportunity to discuss either of the above models of contracting in more detail.  Please submit such request via our “contact us” portal.


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